i. Depression j. Asthma k. Tobacco use 4. Improve by 100% over the baseline from NGHM's other outpatient clinics the patient satisfaction with Chronic Disease Clinic services including supportive social services. 5. Reduce by 25% in year one the number of inappropriate Emergency Room visits, as well as referrals to secondary care, by Chronic Disease Clinic patients. C. The Clinic's focus will be in the following three interventional areas: 1. Prevention services for patients of all ages (insured or not) who either are at risk of having, or who have, diabetes and cardiovascular disease (or both) with diagnostic, wellness and related support services. 2. For patients who have diabetes or CVD or both, provide medical care and lifestyle counseling to help them control adverse health outcomes such as hypertension, stroke, blindness, amputations, kidney failure, or dyslipidemia, etc. 3. Providing physicians practicing at NGHM and SNC clinics with disease management protocols, guidance, health outcomes feedback and eventual continuing medical education (CME) training in order to reduce treatment and prognostic variation in patients with either the pre-diabetes or CVD risk factors, diabetes or CVD and related complications. IV. SUMMARY DESCRIPTION OF CLINIC PROGRAM AND SAFETY NET COLLABORATION In order to enhance the primary, preventive and wellness care services which residents of North Nashville receive, NGHM will establish a Chronic Disease (Metabolic) Clinic. The Clinic's main emphases will be the prevention, diagnosis and treatment of the risk factors associated with, and the chronic conditions of, diabetes and CVD. For those persons who are disease free, NGHM clinicianswill focus on managing associated risk factors such as hypertension, hyperlipidemia, obesity, insulin resistance, etc. NGHM will not conduct this work in isolation, however. Davidson County in general and North Nashville in particular benefit from a set of safety net clinics which provide care to 70,000 patients, the vast majority of whom are indigent or uninsured or both. In tandem with NGHM, these facilities long ago assumed the main responsibility for increasing health care access to needy citizens. The problem, however, is that this formal "Safety Net Consortium of Middle Tennessee" (SNC) has never collaborated to provide both acute care services and long term preventive health and wellness care. The proposed NGHM Clinic, therefore, will provide the central fulcrum around which area SNC providers marshal the resources necessary either to reduce CVD and diabetes risk factors or provide true chronic disease management or both for their patients. While significant patient Page 5 of 35; 18 April 2006 Metropolitan Hospital Authority of Nashville/Davidson County d/b/a Nashville General Hospital at Meharry 1818 Albion Street Nashville, TN 37208-2918 Public Health Service Grant Application: Chronic Disease Center CFD # 93-283 medical history data resides within each particular SNC clinic, there has never been a concerted effort to create a seamless approach to wellness care for area patients. Two years ago, NGHM launched a substantial program to upgrade its inpatient and outpatient medical data systems to an electronic format. With this system now in place, the newly established NGHM Clinic will offer treating, referring, and collaborating physicians an electronic medical record thatfollows their patients[unreadable]no matter at which SNC clinic they seek treatment.6 NGHM's use of the electronic medical record (EMR) will facilitate a new standardization of care across both the hospital's outpatient and inpatient clinics, includingthe new Chronic Disease Clinic. Under the old system physicians, nurses, pharmacists and other allied health care professionals had to rely on a paper based system. This meant that not all of the needed data were available to medical professionals while they treated the patient. With the new EMR system, however, a vast array of patient care, diagnostic, and projmostic data is at hand and just at the click of a mouse. NGHM's physician portal allows physicians from the comfort of their home (e.g., while on call) immediately to access a particular patient's current data sets and to assist with continuity of care remotely. This same benefit will be made available to SNC clinicians through the NGHM Clinic. Over time, both NGHM physicians and other clinicians as well as SNC physicians and clinicians will be able to combine their knowledge and talents to help improve health outcomes in area patients; again, no matter where such patients access the clinic systems[unreadable]whether in or outside of NGHM. Beyond the EMR, NGHM's Clinic also will provide to its physicians and nurses the benefits of a new Lynx system software. This system, which will be leased skirting in July 2006, will augment the medical data and information in the EMR by offering supporting evidence for medical decision making. The Lynx system will identify relevant clinical trials, experimental protocols, conventional treatments, or approaches from complementary or alternative practices. It will help clinicians develop a better understanding of their patient's condition and take a more comprehensive or holistic look at possible therapies. Lynx provides access to expert opinions and current medical research on a host of medical topics. Beyond these data access improvements and inter-clinic electronic compatibility, North Nashville patients would benefit substantially from a new model of care and wellness which addresses pre and post[unreadable]diabetes and CVD issues. NGHM proposes a patient care system that will be individualizedfor each patient based on a protocol framework to be developed as outlined below. This new system will help standardize care by employing yet-to-be established evidence based protocols, which in turn will improve patients' long term outcomes and reduce treatment variation over time. Patients will be encouraged and empowered to "self-activate" and take charge of their own health. The objectives of this prevention, treatment and wellness system follow. 6 NGHM recognizes the Health Insurance Portability and Accountability Act confidentiality issues. Part of the collaboration effort will require inter-SNC/NGHM clinic leadership teams to establish consent protocols which will enable clinicians to follow their patients no matter where within the SNC they access their care. Page 6 of 35; 18 April 2006 Metropolitan Hospital Authority of Nashville/Davidson County d/b/a Nashville General Hospital at Meharry 1818 Albion Street Nashville, TN 37208-2918 Public Health Service Grant Application: Chronic Disease Center CFD # 93-283 V. CHRONIC DISEASE ANDRISK MANAGEMENT PROGRAM TO ACTIVITIES: A. NGHM proposes to implement chronic disease management for patients that is a systematic population-based approach to care delivery, in contrast to current outpatient work, which tends to use episodic, individual-based care. The goal will be to improve the overall health status of North Nashville residents by reducing disparities in access and improving the quality of care each patient receives as those services relate to the prevention and treatment of diabetes and CVD. Initially,NGHM will focus on the establishment of its Chronic Disease Clinic. Central to this Clinic's ultimate design and launch will be the leadership of its Medical Director, who will be a specialist in endocrinology. He or she them will gather the wider hospital physician leadership to focus on the following components for this comprehensive disease management program, including: [unreadable] Ensuring that all patient clinical data resides in the NGHM "EMR", electronic medical record. [unreadable] Sharing knowledge on how best to serve hard-to-reach patients, particularly those who do not make appointments (e.g., walk-ins) or skip out on scheduled visits. This skill set will hinge on the wider "entry point" mechanism through which area patients enter the SNC and the NGHM clinics. [unreadable] Engaging NGHM physician leadership on the delivery system design, which will mean changes at the encounter level that incorporate pro-active, planned visits around the chronic disease risk factors and use of a team approach, with active follow-up. [unreadable] BolsteringNGHM's decision support department, including the separate purchase ofnew decision support software. This system will support evidence-based guidelines and clinical pathways enabling NGHM clinicians to manage patient care more tightly and reduce outcomes variation. [unreadable] Establishing or supporting or both those community service agencies and assets inNorth Nashville which will help clinicpatients find long term supplemental wellness support. [unreadable] Establishing patient self-management support programs which emphasize their unique role in managing their risk and if they have chronic disease, their illness. Operating in parallel to NGHM's Clinic launch will be the collaborative planning with SNC clinic leadership. Once the Clinic is fully established, the Clinic's Medical Director then will be in an ideal position to guide this wider collaborative effort by forming an interdisciplinary team within the NGHM leadership and with representation from the SNC. The network team will begin envisioning and planning how to implement best practices and to oversee the implementation of clinic care guidelines. This network, now infoimal, will enable otherwise disparate physicians and nurses to coordinate care for area patients who enter the SNC at any of its various member clinics. Many aspects of patients' lives affect their health, and no one profession encompasses the background to meet all the wellness needs of area patients. Having various disciplines work together within the framework of the SNC will help ensure that Page 7 of 35; 18April 2006